Multimodal Monitoring for Hemodynamic Categorization and Management of Pediatric Septic Shock: A Pilot Observational Study

Objectives: To evaluate the cardiovascular aberrations using multimodal monitoring in fluid refractory pediatric septic shock and describe the clinical characteristics of septic myocardial dysfunction. Design: Prospective observational study of patients with unresolved septic shock after infusion of 40mL/kg fluid in the first hour. Setting: Two tertiary care referral Indian PICUs. Patients: Patients aged 1 month to 16 years who had fluid refractory septic shock. Interventions: Changes in therapy were based on findings of clinical assessment, bedside echocardiography, and invasive blood pressure monitoring within 6 hours of recognition of septic shock. Measurements and Main Results: Over a 4-year period, 48 patients remained in septic shock despite at least 40mL/kg fluid infusion. On clinical examination, 21 patients had cold shock and 27 had warm shock. Forty-one patients (85.5%) had vasodilatory shock on invasive blood pressure; these included 14 patients who initially presented with cold shock. The commonest echocardiography findings were impaired left right ventricular function in 19 patients (39.6%) and hypovolemia in 16 patients (33%). Three patients who had normal myocardial function on day 1 developed secondary septic myocardial dysfunction on day 3. Echocardio graphy, along with invasive arterial pressure monitoring, allowed fluid, inotropy, and pressors to be titrated more precisely in 87.5% of patients. Shock resolved in 46 of 48 patients (96%) and 44 patients (91.6%) survived to discharge. Conclusion: Bedside echocardiography provided crucial information leading to the recognition of septic myocardial dysfunction and uncorrected hypovolemia that was not apparent on clinical assessment. With invasive blood pressure monitoring, echocardiography affords a simple noninvasive tool to determine the cause of low cardiac output and the physiological basis for adjustment of therapy in patients who remain in shock despite 40mL/kg fluid.